This is a blog by a former CEO of a large Boston hospital to share thoughts about negotiation theory and practice, leadership training and mentoring, and teaching.

Thursday, March 14, 2013

Fool me once, shame on you; fool me twice, shame on me

The people at Intuitive Surgical, the folks who made a fortune by marketing robotic prostate surgery to men across America, can't be having much fun right now. They have been hoping to expand their business in obstetrics and gynecology. But look at these comments by James T. Breeden, president of ACOG:

Many women today are hearing about the claimed advantages of
robotic surgery for hysterectomy, thanks to widespread marketing and
advertising. Robotic surgery is not the only or the best minimally
invasive approach for hysterectomy. Nor is it the most cost-efficient.
It is important to separate the marketing hype from the reality when
considering the best surgical approach for hysterectomies.

Robotic hysterectomy generally provides women with a shorter
hospitalization, less discomfort, and a faster return to full recovery
compared with the traditional total abdominal hysterectomy (TAH) which
requires a large incision. However, both vaginal and laparoscopic
approaches also require fewer days of hospitalization and a far shorter
recovery than TAH. These two established methods also have proven track records for outstanding patient outcomes and cost efficiencies.

At a time when there is a demand for more fiscal responsibility and
transparency in health care, the use of expensive medical technology
should be questioned when less-costly alternatives provide equal or
better patient outcomes.

At a price of more than $1.7 million per robot, $125,000 in annual
maintenance costs, and up to $2,000 per surgery for the cost of
single-use instruments, robotic surgery is the most expensive approach. A
recent Journal of the American Medical Association study found
that the percentage of hysterectomies performed robotically has jumped
from less than 0.5% to nearly 10% over the past three years. A study of
over 264,000 hysterectomy patients in 441 hospitals also found that
robotics added an average of $2,000 per procedure without any
demonstrable benefit.

[A]n estimated $960 million to $1.9 billion will be added to the
health care system if robotic surgery is used for all hysterectomies
each year.

Aggressive direct-to-consumer marketing of the latest medical
technologies may mislead the public into believing that they are the
best choice. Our patients deserve and need factual information about all
of their treatment options, including costs, so that they can make
truly informed health care decisions. Patients should be advised that
robotic hysterectomy is best used for unusual and complex clinical
conditions in which improved outcomes over standard minimally invasive
approaches have been demonstrated.

8 comments:

I remember when you were agonizing over whether/having to invest in robotic prostate equipment at the hospital because it was "all the rage" and the men would demand it and go elsewhere if not provided. Wonder if the outcomes are the same.

My extremely awesome urologist/surgeon Drew Wagner, who removed my kidney and adrenal gland laparoscopically *with bare hands*, says he does use robots sometimes. They're extremely precise, not shaky, etc, for very fine work. The problem as Paul's wording suggests, is that their marketing *increases* the amount of surgery, instead of just improving the quality of existing surgery. And since all surgery involves risk of harm, such marketing causes harm, IMO.

It is my understanding that robotic procedures are always longer than comparable human (non-robotic) procedures. This increases the risk of infection of the open incision and risks associated with anesthesia.

This is another classic example of why doctors need to embrace knowing and caring about costs as an important part of their job. We need robust, user friendly price and quality transparency tools to help them do that with as little incremental demand on their time as possible.

Too bad unnecessary robotic surgery is not part of the choosing wisely campaign. Given the track record with Prostate surgery this (hysterectomy by robot) may become the norm as people vote with their feet based on the marketing hype. At our hospital we lost nearly all our prostatectomies to other institutions when we decided not to get a robot because there was no proven clinical advantage. Plus more and more residents are being trained primarily on the robot so if you don't have one it becomes harder to recruit surgeons. Needless to say we now own a robot for surgeries.

What needs to be said more: separate the marketing hype from reality when it comes to the selection of surgical techniques. We can no longer just "trust" docs when they say shorter recovery time, etc. We need to "verify" first, then we can trust, or at least hope for the best outcome.

And by what mechanisms do you suggest that we laypeople "verify" competing claims from experts whose financial incentives and associations are sure to be hidden from us, and when it is now apparently the norm for studies funded by commercial enterprises to include non-disclosure agreements and non-publication clauses that become operative when results are open to question or (especially) negative?